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Don't forget the hip! Hip arthritis masquerading as knee pain.

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Title:
Don't forget the hip! Hip arthritis masquerading as knee pain.
Series Title:
Arthroplast Today. 2017 Aug 12;4(1):118-124. doi: 10.1016/j.artd.2017.06.008. eCollection 2018 Mar.
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Parvataneni, Hari
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Elsevier
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English
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Journal Article

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Abstract:
BACKGROUND: Hip osteoarthritis typically manifests with groin or thigh pain. Other atypical pain patterns, including knee pain, have been described. Except for 2 case reports, there is no literature on this subject. METHODS: From our institutional database, between 2011 and 2016, we identified 21 patients who were referred for treatment of knee pain but ultimately diagnosed with hip pathology as the cause of their pain. This group was evaluated for duration of symptoms prior to diagnosis, previous interventions, presence of walking aids, and symptom resolution after treatment of the hip pathology. RESULTS: Fifteen of the 21 patients were referred from musculoskeletal providers (12 from orthopaedic surgeons). Prior to diagnosis of the hip etiology, 16 patients were reduced to major assistive devices including wheelchairs. Twelve of 21 patients had undergone surgical knee interventions, including total knee arthroplasty, with minimal to no relief of their pain. Seventeen of 21 referred patients underwent total hip arthroplasty at our institution. Fourteen patients had complete resolution of knee pain after total hip arthroplasty. CONCLUSIONS: Although knee pain referred from hip disease may be considered a basic and common knowledge, it continues to be an overlooked phenomenon. Most of the cases were misdiagnosed by musculoskeletal providers including orthopaedic surgeons and this highlights the need for continued education and awareness of this clinical scenario.
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Collected for University of Florida's Institutional Repository by the UFIR Self-Submittal tool. Submitted by Hari Parvataneni.

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OriginalresearchDon'tforgetthehip!HiparthritismasqueradingaskneepainFlorianF.Dibra,MD,HernanA.Prieto,MD,ChancellorF.Gray,MD, HariK.Parvataneni,MD*DepartmentofOrthopaedicSurgeryandRehabilitation,UniversityofFlorida,Gainesville,FL,USAarticleinfoArticlehistory: Received22June2017 Receivedinrevisedform 28June2017 Accepted29June2017 Availableonline12August2017 Keywords: Hippain Kneepain Referredpain Delayindiagnosis UnnecessarysurgeryabstractBackground: Hiposteoarthritistypicallymanifestswithgroinorthighpain.Otheratypicalpainpatterns, includingkneepain,havebeendescribed.Exceptfor2casereports,thereisnoliteratureonthissubject. Methods: Fromourinstitutionaldatabase,between2011and2016,weidenti ed21patientswhowere referredfortreatmentofkneepainbutultimatelydiagnosedwithhippathologyasthecauseoftheir pain.Thisgroupwasevaluatedfordurationofsymptomspriortodiagnosis,previousinterventions, presenceofwalkingaids,andsymptomresolutionaftertreatmentofthehippathology. Results: Fifteenofthe21patientswerereferredfrommusculoskeletalproviders(12fromorthopaedic surgeons).Priortodiagnosisofthehipetiology,16patientswerereducedtomajorassistivedevices includingwheelchairs.Twelveof21patientshadundergonesurgicalkneeinterventions,includingtotal kneearthroplasty,withminimaltonoreliefoftheirpain.Seventeenof21referredpatientsunderwent totalhiparthroplastyatourinstitution.Fourteenpatientshadcompleteresolutionofkneepainafter totalhiparthroplasty. Conclusions: Althoughkneepainreferredfromhipdiseasemaybeconsideredabasicandcommon knowledge,itcontinuestobeanoverlookedphenomenon.Mostofthecasesweremisdiagnosedby musculoskeletalprovidersincludingorthopaedicsurgeonsandthishighlightstheneedforcontinued educationandawarenessofthisclinicalscenario. 2017TheAuthors.PublishedbyElsevierInc.onbehalfofTheAmericanAssociationofHipandKnee Surgeons.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense( http://creativecommons.org/ licenses/by-nc-nd/4.0/ ).Introduction Osteoarthritis(OA)isacommondiagnosisinambulatoryprimarycarevisits,withanincidenceof21.7million,andaccountsfor 47.5%ofallarthritis-relatedhospitalizationsannually [1,2] .Inindividuals > 45-years-old,prevalenceofhipandkneeOAis28%and 37%,respectively [3,4] .Patientsusuallypresentwithpain,stiffness, andprogressivelossoffunction [5] .WithhipOA,groinpainisthe classicandmostcommonpresentingsymptom [6-9] .However,less commonly,hippathologycanalsorefertothebuttock,thigh,knee, anddistalleg [6-10] Atypicalpresentationofhiparthritiscanbeadiagnosticchallenge.Referredpainfromthehiptothebuttockorlowbackcanbe misdiagnosedasspinepathology.Leeetal [11] describedaprevalenceof32.5%ofhippathologyonpreoperativeabdominalradiographsofpatientswhounderwentspinesurgery.Inaddition,the prevalenceofkneepaincausedbyhippathologyhasbeenreported between2%and29% [6,7,9,10,12] .Whenapatientpresentswith persistentkneepain,healthcareprovidersmaycontinueto consideritasthesolesourceofthepainevenifitisnotthepain generator.Thiscontinuedfocuscanbedrivenbythelimitedsoft tissueinformationprovidedbyplainradiographsandthebroad differentialforkneepainduetoitsintricateanatomy. Inthesettingofabenignkneeexaminationandinconclusive imaging,cliniciansmustconsiderextrinsicsourcesforkneepain suchasthethigh,hip,orlowback.Hippathologypresentingas kneepainisawell-describedphenomenoninthepediatricliterature,typicallyrelatedtoaslippedcapitalfemoralepiphysisor Legg-Calves-Perthesdisease [13-15] .Toourknowledge,theadult literatureregardingthistopicissparseandlimitedtoafewsmall caseseries [16,17] .Theprimarypurposeofthisstudyistodescribea cohortofpatientsevaluated,treated,andthenreferredfor Oneormoreoftheauthorsofthispaperhavedisclosedpotentialorpertinent con ictsofinterest,whichmayincludereceiptofpayment,eitherdirectorindirect, institutionalsupport,orassociationwithanentityinthebiomedical eldwhich maybeperceivedtohavepotentialcon ictofinterestwiththiswork.Forfull disclosurestatementsreferto http://dx.doi.org/10.1016/j.artd.2017.06.008 Correspondingauthor.3450HullRoad,Gainesville,FL32607,USA.Tel.: 1352 2737002. E-mailaddress: parvataneni@u .edu Contentslistsavailableat ScienceDirectArthroplastyTodayjournalhomepage: http://www.arthroplastytoday.org/ http://dx.doi.org/10.1016/j.artd.2017.06.008 2352-3441/ 2017TheAuthors.PublishedbyElsevierInc.onbehalfofTheAmericanAssociationofHipandKneeSurgeons.ThisisanopenaccessarticleundertheCCB Y-NCNDlicense( http://creativecommons.org/licenses/by-nc-nd/4.0/ ). ArthroplastyToday4(2018)118 e 124

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recalcitrantkneepain,whichwaseventuallydeterminedtobedue tounderlyinghiparthritis. Materialandmethods ThisretrospectivestudywasapprovedbytheInstitutionalReviewBoard.Between2011and2016,weidenti edpatientswho werereferredprimarilyfortheevaluationandtreatmentof persistentkneepainbutwerefoundtohavehiparthritisasthe causeofthekneepain.Inourpractice,allpatientswhopresent withkneepainalsogetaphysicalexaminationofthehips;whena differenceinrangeofmotionisnotedbetweensides,ananteriorposteriorpelvisandlateralhipradiographisobtained,sometimes leadingtoadiagnosisofhipOA.Wereviewedthemedicalrecords, aswellasradiographicimaging,consistingofstandardizedhipand kneeradiographs.T € onnisclassi cationandKellgrenandLawrence systemwereusedbytheauthorsforgradingradiographichipand kneearthritis,respectively [18-20] .Demographicinformation, previoustreatments(surgicalandnonsurgical),specialtyofreferringprovider,useofwalkingaids,severityofkneeandhiparthritis, delayindiagnosis,treatmentreceivedafterdiagnosis,andresponse totreatmentwereobtainedfromthemedicalrecords. Results Twenty-onepatientswereidenti edandincludedinourreview.Fifteenofthe21patientswerereferredfrommusculoskeletal providers,includingorthopaedicsurgeons,primarysportsmedicinepractitioners,andphysiatrists.Ofthatsubgroup,12patients weresentbyorthopaedicsurgeonsforasecondopinion.Delayin diagnosiswasgreaterthanayearfor18of21patients. Priortopresentationinourclinic,allthepatientshadundergonesurgicalornonsurgicalkneeinterventionfortheirpain. Elevenof21patientshadundergoneintra-articularkneeinjection (viscosupplementationorcorticosteroid)and5hadadvancedimagingperformed,suchaskneeorspinemagneticresonanceimaging.Elevenof21patientshadundergonekneesurgeryincluding 3arthroscopiesand8totalkneearthroplasties(TKAs).Twoofthe arthroplastypatientsunderwentrevisionTKAatoutsideinstitutionsduetounrelentingkneepain. Interestingly,signi cantdisabilitywasnotedinourpatients, with12of21patientsrequiringuseofawalkerorwheelchairfor ambulation.Thatnumberwasevengreater(16patients)when includingacaneasawalkingaid. Seventeenof21patientseventuallyunderwentipsilateraltotal hiparthroplasty(THA)fortheirpain,with2ofthese17patients havingundergonebilateralTHAforkneepainonbothsides. Fourteenofthe17patientsexperiencedcompleteresolutionof theirkneepain.Postoperatively,12patientsexperiencedimprovementsintheirdisabilityasnotedbyuseofwalkingaids.The patientsrequiringpreoperativeuseofawheelchairtypically downgradedtoawalkerorcane,postoperatively,whilethoseusing awalkerpreoperativelywereabletobedowngradedtouseofa caneornowalkingaids. Threepatientsreportedonlypartialimprovementoftheirknee painafterTHA.OnepatientwasreferredtochronicpainmanagementforgeniculatenerveblockinjectionswithotherwiseunremarkableworkupofherpreviouslydoneTKA.Anotherwasreferred tosportsmedicineformeniscalpathologyfoundonmagnetic resonanceimagingoftheknee.Interestingly,thepatientwith meniscalpathologyhadaprevioushistoryofcontralateralknee painduetohiparthritisandhehadcompleteresolutionofknee painwithTHA.Thethirdpatientisbeingtreatedconservatively withanti-in ammatories. Fourpatientsinourseriesdidnotundergode nitivetreatment oftheirhipdiseaseatourinstitution.Onepatientexpiredpriorto surgery;1wasreferredfortreatmentclosertohome;andanother patientwaslosttofollow-up.Finally,1patientunderwentanintraarticularsteroidinjectionofhishipwithtemporarycompleterelief ofhiskneepain;heisawaitingTHApendingmedicaloptimization. Completepatientdetailsandoutcomesareincludedin Table1 Wehighlight3particularlyillustrativecasesin Figures1-7 Discussion Toourknowledge,therehavebeenonlyisolatedcasereportsof hippathologymasqueradingaskneepainintheadultpopulation, andthisisthelargestseriestodateonthissubject [16,17] .We highlighttheimportanceofmaintainingahighindexofsuspicion whenpatientspresentwithkneepain,anddisabilitydisproportionatetotheirradiographicdisease,especiallyiftheirsymptoms arerefractorytointerventions.Ifpatientshavepredominantlyknee painbutaredependentonawalkerforambulationorinawheelchair,thesuspicionforamoreproximalsourceofthepainor disabilityshouldbehigh. Thehipandkneejointsreceivemultiplesensoryinnervations. Inthehip,theobturatorandfemoralnervessupplythehipcapsuleanteriorly,whilesciaticandsuperiorglutealnervessupplyitposteriorly [21] .Intheknee,anterior bersoriginatefromthefemoral, saphenous,andcommonperonealnerves,whileposterior bers originatefromthetibialandobturatornerves [22] .Perhapsthe crossoverininnervationcouldexplainthereferralpatternsofhip disease;however,theneuralmechanismshavenotbeenfully elucidated. Earlytheoriesexplainingthepathophysiologyofreferredpain includeRuch's [23] convergence-projectiontheory,whichdescribes theconvergenceofsomaticandvisceral bersdirectlyontoone dorsalhornneuroninthespinalcord.Sinclairpostulatedthatthe somaticandvisceral bersconvergedontoanafferentneuron beforereachingthespinalcord [24] .Sincetheiroriginaldescriptions,somestudiesseemtosupportRuch'stheory;however, thetopicremainspoorlyunderstood [25,26] .Miuraetal [27] ,using aratmodel,demonstratedthatasmallpercentageofalldorsalroot ganglionneuronsinnervatingthehipjointshadotheraxonsthat extendedtothemedialportionofkneeskin.Thesedichotomizing bersmayalsoexplainreferredkneepainoriginatingfromhip jointpathology. Inhumans,theprecisesensoryinnervationpatternandcorrelationofthesensorynervesinthehipandkneeremainsunknown. Thisisespeciallytrueinpatientswithpersistentkneepainafter THA [28] .Onepotentialexplanationforpersistentkneepaincould bethatthemuscletowhichpainisreferredforaprolongedperiod oftimemayitselfbecomeageneratorofpain [10] .Thishighlights theimportanceofaswiftdiagnosisinpatientsthatcouldbeprone tosuchreorganizationoftheirneuralpainpathways. Inthecurrenthealthcareeconomicclimate,theburdenof arthritisisprojectedtoincreaseinthecomingyears.Bytheyear 2040,anestimated78millionadults,olderthan18yearsofage,will haveadiagnosisofarthritis [29] .Currently,totaldirectandindirect annualcostsofmanagingOAperpatientareestimatedat$5700 [30] .Withtheanticipatedprojectionoffuturepatientsandthe standardhighcostassociatedwithOA,patientscannotaffordunnecessarytestingandinterventions,especiallywhentheyresultin adelayinaccuratediagnosis. Moreover,patientssufferingfromOAhaveahighermorbidity countandare2-3timesmorelikelytosufferfromanxietyand depression,whichleadstolimitationsinactivityandmorepainand overalldisability [31,32] .QuicklyandadequatelyaddressingtheirF.F.Dibraetal./ArthroplastyToday4(2018)118 e 124 119

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Table1 Patientinformationhighlightingdiagnosis,priorkneetreatments,andoutcomesaftertreatmentofthehippathology. Patient(age/gender)Priortreatment/diagnosticstudiesAssistivedevice priortodiagnosis Delayin diagnosis Kneeosteoarthritis classi cationaHiposteoarthritis classi cationbTreatmentAssistivedevice afterintervention Kneepainresolution NonoperativeOperative 85/Male( Figs.1 and 2 )CSI,PTRightrevisionTKAWalker > 1yProsthesisGrade3RightTHANoneCompleterelief 70/FemalePTRightrevisionTKAWalker > 1yProsthesisGrade3RightTHANoneCompleterelief 93/MaleCSI,VSRightTKAWheelchair < 1yProsthesisGrade3RightTHACaneCompleterelief 61/MalePTLeftTKANone > 1yProsthesisGrade3LeftTHANoneCompleterelief 69/MalePTBilateralTKAWalker > 1yProsthesisGrade3BilateralTHACaneCompleterelief 86/FemaleCSILeftTKAWalker < 1yGrade3Grade3LeftTHANoneCompleterelief 91/MaleNoneNoneWheelchair > 1yProsthesisGrade3RightTHACaneCompleterelief 52/FemaleCSI,PT,kneeMRI 2NoneWheelchair > 1yGrade2Grade3LeftTHANoneCompleterelief 66/Male( Figs.3 and 4 )PTNoneNone > 1yGrade0Grade3LeftTHANoneCompleterelief 83/MaleCSINoneWalker > 1yGrade1Grade3LeftTHACaneCompleterelief 78/FemalePTNoneWalker < 1yGrade0Grade3RightTHACaneCompleterelief 71/MaleNoneNoneCane > 1yGrade2Grade3RightTHANoneCompleterelief 66/Male( Figs.5-7 )PTNoneCane > 1yGrade1:left Grade2:right Grade3:bilateralBilateralTHANoneCompleterelief 85/FemaleCSI,VS,right commonperoneal block,MRIlumbar spine,lumbarspine ESI NoneCane > 1yGrade2Grade3RightTHACaneCompleterelief 64/MaleCSI,PT,braceNoneWheelchair > 1yGrade1Grade3RightTHACanePartialrelief 77/MaleCSI,PT,kneeMRIRightknee arthroscopy Notdocumented > 1yGrade1Grade3RightTHANonePartialreliefc76/FemalePTRightTKANone > 1yProsthesisGrade3RightTHANonePartialreliefd51/MaleCSI,VSkneeMRINoneCane > 1yGrade2Grade3THApendingPendingKneepainresolved withhipCSI 83/FemalePTLeftTKAWheelchair > 1yProsthesisGrade3Losttofollow-upLosttofollow-upLosttofollow-up 64/FemaleCSILeftknee arthroscopy Notdocumented < 1yGrade1Grade3ReferredforTHALosttofollow-upLosttofollow-up 74/MaleCSI,PT,kneeMRILeftknee arthroscopy Walker > 1yGrade2Grade3Diedbefore treatment Diedbefore treatment Diedbefore treatment CSI,corticosteroidinjection;ESI,epiduralsteroidinjection;MRI,magneticresonanceimaging;PT,physicaltherapy;VS,viscosupplementatio n.aKellgrenandLawrencesystemforclassi cationofosteoarthritisoftheknee.bT € onnisclassi cationofosteoarthritisofthehip.cPatientwasreferredtosportsmedicineformeniscalpathology.dPatientwasreferredtopainmanagementforgeniculatenerveblockade.F.F.Dibraetal./ArthroplastyToday4(2018)118 e 124 120

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osteoarthriticneedsisessentialtoexpeditetheirreturntoactivities andultimatelyrestoreoverallhealthandwell-being. Therearecertainlimitationstothisstudy.Theretrospective natureofthiscaseseriesimpartsobservationalandselection biases.Casespresentedinthisserieswererecordedover5yearsby thetreatingsurgeonswhodiagnosedtheirhipdisease.Itislikely that,duringtheperiodstudied,patientswithkneepainfromhip pathologycouldhavebeenmissediftheindexofsuspicionwaslow Figure1. Eightyve-year-oldmalewhounderwentrevisionkneesurgeryforseveralyearsofrightkneepainbutwithoutrelief.Kneeradiographsrevealedrevisionkne eprosthesis withoutanyobviousetiologyofthekneepain. Figure2. Eightyve-year-oldmalewhounderwentrevisionkneesurgeryforseveralyearsofrightkneepainbutwithoutrelief.Righthipradiographs(a)revealedGrad e3OA. KneepaincompletelyresolvedafterrightTHA(b). F.F.Dibraetal./ArthroplastyToday4(2018)118 e 124 121

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orthepainseverityandrelateddisabilitywerelow.Additionally,it wouldbeverydif culttodetermineifpatientswithhippathology presentingaskneepainsoughttreatmentelsewherebeforethis wasrecognized.Consideringthis,theauthorsdonotfeelthat estimatingaprevalenceofkneepainrelatedtohiparthritiswould beaccurateandwouldinfactlikelygrosslyunderestimatethe prevalence.Theprevalenceofthishasbeenhighlyvariableinthe literatureandisbetween2%and29% [6,7,9,10,12] .Thisfurther con rmsthatanestimationwouldnotbeaccurate.Inselectpatients,therewasincompleteinformationregardingprevious Figure3. Sixty-six-year-oldmalewith18monthsofleftkneepain.KneeradiographsrevealedGrade0OA. Figure4. Sixty-six-year-oldmalewith18monthsofleftkneepain.Hipradiographs(a)revealedGrade3OA.KneepaincompletelyresolvedafterleftTHA(b). F.F.Dibraetal./ArthroplastyToday4(2018)118 e 124 122

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treatmentsreceivedoutsideourinstitution,aswellaspriorradiographicstudies,whichwouldhaveprovidedadditionalvaluable informationtoourstudy.Finally,therewerenopatient-reported outcomedatabeforeandaftertheirhipreplacement,onlysubjectivereportsofreliefoftheirkneepain. Conclusions Referredpainfromthehiptothekneecanbemisleadingto healthcareprovidersincludingmusculoskeletalproviderswho evaluated15ofthe21patientsinourseries.Sometimesthe referredpaincanbedif culttobelievebythepatientthemselves. Wehighlightthefollowingwarningsignsthatshouldprompt investigationofthehipasapotentialunderlyingsourceofknee pain:kneepainoutofproportiontoclinicalandradiographic ndingsrelatedtotheknee;signi cantdisabilityanduseof walkingaids(especiallyawheelchairorwalker);abnormalhip motionduringphysicalexaminationandkneepainthatfailsto improvewithkneeinterventions.Thisconstellationof ndings shouldraisetheindexofsuspiciontoevaluateextrinsicsourcesfor kneepain,especiallythehip.Improvedawarenessofthisissuemay morequicklyleadtoanaccuratediagnosis,timelytreatmentofthe sourceofpain,andpreventunnecessaryinterventionsforaffected patients.Althoughitisconsideredabasicknowledgeinorthopaedicsurgery,thiscaseserieshighlightstheimportanceof continuededucationandawarenessofthisclinicalscenariowhich canstillleadtomisdiagnosisandmistreatmentbymusculoskeletal providers. Figure5. Sixty-six-year-oldmalewithseveralyearsofbilateralkneepain.KneeradiographsrevealedGrade2rightkneeOAandGrade1leftkneeOA. Figure6. Sixty-six-year-oldmalewithseveralyearsofbilateralkneepain.HipradiographsrevealedGrade3bilateralhipOA. Figure7. Sixty-six-year-oldmalewithseveralyearsofbilateralkneepain.Kneepain completelyresolvedafterbilateralTHA. F.F.Dibraetal./ArthroplastyToday4(2018)118 e 124 123

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